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DWC-1 Request and Injury-Reporting Checklist
Use this tool now
Request the DWC-1 in writing, complete only the employee section, return it with proof of delivery, and keep the employer-completed copy with the injury report.
How to use it
- 1.Use one checklist for each DWC-1 claim form you are organizing.
- 2.Check each action only after saving its proof.
- 3.Keep the finished checklist with the claim file.
Checklist
DWC-1 Request and Injury-Reporting Checklist
Report the injury to a supervisor in writing
Record the date, time, recipient, work task, and affected body parts.
Request the DWC-1 claim form
Save the request if the employer did not provide the form.
Complete the employee section
Sign and date it; do not fill in the employer section.
Return the form using a traceable method
Save the email, portal receipt, certified-mail receipt, or signed hand-delivery copy.
Request the employer-completed copy
Keep the claim number and claims-administrator details with it.
Save the first medical and work-status records
Tell medical staff the injury is work-related.
Record every follow-up
Log who responded, what was said, and the date.
Avoid
- — Do not assume an incident report replaces the DWC-1.
- — Do not send away the only copy.
Keep with this tool
- — Written injury notice
- — Employee and employer DWC-1 copies
- — Delivery proof
- — First medical record
- — Work-status slip
- — Carrier and claim details
Common questions
What if the employer never gives me the form?
DWC says a worker may download the form or contact its Information and Assistance Unit. Keep the written request and delivery proof.
Does this checklist calculate my filing deadline?
No. Reporting, filing, service, and claim facts can differ. This tool records dates for later review.
Should I describe every affected body part?
Use accurate language based on what happened and what you know. Do not guess or exaggerate.
Read the deeper explanation
Hurt at Work and Never Got a DWC-1 Claim Form? What California Workers Should SaveAuthoritative sources
Check the linked official source for current forms and rules. Updated: .
WCLG
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